Basic Information
| Provider Information | |||||||||
| NPI: | 1265521934 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIERBERGS MARKETS INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DIERBERGS TOWN CENTER PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1070 | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630061070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6368121470 | ||||||||
| FaxNumber: | 6368121603 | ||||||||
| Practice Location | |||||||||
| Address1: | 2460 TAYLOR RD | ||||||||
| Address2: | |||||||||
| City: | GROVER | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630401222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6364587450 | ||||||||
| FaxNumber: | 6365303002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 01/30/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GUENTHER | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PHARMACY | ||||||||
| AuthorizedOfficialTelephone: | 6368121470 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | 2003031656 | MO | N | Suppliers | Pharmacy | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 606120103 | 05 | MO | MEDICAID | 2635362 | 01 | OTHER ID NUMBER-COMMERCIAL NUMBER | OTHER |